Forms: MONY/MLOA or USFL Life Insurance

Life insurance claims are paid after the Company ensures:

• You are the true beneficiary
• The policy is current and in force
• That all conditions of the policy have been met

Required Documents

When filing a claim, these documents are necessary:

• Claim to MONY Life Insurance or Annuity Benefits Form
  For CO, FL, KS, MD, ND, NV, or NY states only (Required for all beneficiaries listed on the policy)
• Claim to MONY Life Insurance or Annuity Benefits Form 
   For all other states (Required for all beneficiaries listed on the policy)
• Claim to USFL Life Insurance Form 
  (Required for all beneficiaries listed on USFL policies) 
• Original life insurance policy, if available  
• Certified copy of death certificate
• Any additional claim form that is required for the payment option you have selected (see additional option forms below)

Important Notice: Your claim may qualify for Express Processing with no additional forms required if filing a claim for $50,000 or less.  Please call our toll free number (800) 659-1058, Monday through Friday, 8:30 AM to 5:00 PM (Eastern) for further information. 

Additional Documents

Not all options are available to all beneficiaries.  Depending on your personal situation, these additional documents may be necessary:

• Specified Income Options 
  Available when requesting claim proceeds as an income for a specified period or specified amount
• Life/Income Options
  Available when requesting claim proceeds as a life income
• Interest Options
  Available when requesting claim proceeds in an interest bearing contract
• Assignment of Benefits Form
  Available when assigning all or part of claim proceeds to another party
• Statement as to Children Form
  Available if the beneficiaries are the children of the insured, but not named in the beneficiary provision and/or if the policy covers more than the deceased person (i.e. children’s term rider, additional insured rider, etc.)
• Tax Withholding Election Statement - Special Payment (W-4P) Form 
  Available  if a specified income option or life income option is elected   
• Certificate of Appointments
  If you are filing as executor, administrator or guardian
• Copy of Trust Excerpts
  Title, appointment and signature pages and any amendment naming the successor trustee(s)
• Beneficiary Guide
  To assist with important decisions after the loss of a loved one

Return all documents for MONY/MLOA to:

Regular Mail:

MONY, an AXA Financial Company
PO Box 4830
Syracuse, NY 13221

Express Mail:

MONY, an AXA Financial Company
100 Madison Street
Syracuse, NY 13202

Return all documents for USFL to:

Regular Mail:

USFL, An AXA Financial Company
PO Box 4763
Syracuse, NY 13221

Express Mail:

USFL, an AXA Financial Company
100 Madison Street
Syracuse, NY 13202

FAX:

MONY/MLOA - (315) 477-4357
USFL- (315) 477-2144

You may also request these forms be mailed to you by calling:

• MONY/MLOA toll free number (800) 659-1058, Monday through Friday, 8:00 AM to 5:00 PM (Eastern)
• USFL toll free number (800) 959-3894, Monday through Friday, 8:30 AM to 4:30 PM (Eastern) 
• The policyholder’s Financial Professional  

If you need assistance at any time, we recommend that you check with your Financial Professional, Talk To An AXA Advisors, LLC Financial Professional or contact the customer service area applicable to your situation. 

These forms are Portable Document Format (PDF) files. If your browser is not yet capable of reading PDF files, you can download the free Adobe® Acrobat Reader™ software at the following link: http://www.adobe.com/prodindex/acrobat/readstep.html. Instructions for installation are also found at that location.